In hepatorenal syndrome (HRS), renal insufficiency is often progressive, and the prognosis is extremely poor under standard medical therapy. The molecular adsorbent recirculating system (MARS) is a modified dialysis method using an albumin-containing dialysate that is recirculated and perfused online through charcoal and anion-exchanger columns. MARS enables the selective removal of albumin-bound substances. A prospective controlled trial was performed to determine the effect of MARS treatment on 30-day survival in patients with type I HRS at high risk (bilirubin level, > or =15 mg/dL) compared with standard treatment. Thirteen patients with cirrhosis with type I HRS were included from 1997 to 1999. All were Child's class C, with Child-Turcotte-Pugh scores of 12.4 +/- 1. 0, United Network for Organ Sharing status 2A, and total bilirubin values of 25.7 +/- 14.0 mg/dL. Eight patients were treated with the MARS method in addition to hemodiafiltration (HDF) and standard medical therapy, and 5 patients were in the control group (HDF and standard medical treatment alone). None of these patients underwent liver transplantation or received a transjugular intrahepatic portosystemic shunt or vasopressin analogues during the observation period. In the MARS group, 5.2 +/- 3.6 treatments (range, 1 to 10 treatments) were performed for 6 to 8 hours daily per patient. A significant decrease in bilirubin and creatinine levels (P <.01) and increase in serum sodium level and prothrombin activity (P <.01) were observed in the MARS group. Mortality rates were 100% in the control group at day 7 and 62.5% in the MARS group at day 7 and 75% at day 30, respectively (P <.01). We conclude that the removal of albumin-bound substances with the MARS method can contribute to the treatment of type I HRS.
Liver failure associated with excretory insufficiency and jaundice results in an endogenous accumulation of toxins involved in the impairment of cardiovascular, kidney, and cerebral function. Moreover, these toxins have been shown to damage the liver itself by inducing hepatocellular apoptosis and necrosis, thus creating a vicious cycle of the disease. We report a retrospective cohort study of 26 patients with acute or chronic liver failure with intrahepatic cholestasis (bilirubin level > 20 mg/dL) who underwent a new extracorporeal blood purification treatment. A synthetic hydrophilic/hydrophobic domain-presenting semipermeable membrane (pore size < albumin size, 100-nm thick) was used for extracorporeal blood detoxification using dialysis equipment. The opposite side was rinsed with ligandin-like proteins as molecular adsorbents that were regenerated online using a chromatography-like recycling system (molecular adsorbent recirculating system [MARS]). Bile acid and bilirubin levels, representing the previously described toxins, were reduced by 16% to 53% and 10% to 90% of the initial concentration by a single treatment of 6 to 8 hours, respectively. Toxicity testing of patient plasma onto primary rat hepatocytes by live/dead fluorescence microscopy showed cell-damaging effects of jaundiced plasma that were not observed after treatment. Patients with a worsening of Child-TurcottePugh (CTP) index before the treatments showed a significant improvement of this index during a period of 2 to 14 single treatments with an average of 14 days. After withdrawal of MARS treatment, this improvement was sustained in all long-term survivors. Ten patients represented a clinical status equivalent to the United Network for Organ Sharing (UNOS) status 2b (group A1), and all survived. Sixteen patients represented a clinical status equivalent to UNOS status 2a, and 7 of these patients survived (group A2), whereas 9 patients (group B) died. We conclude that in acute excretory failure caused by a chronic liver disease, this treatment provides a therapy option to remove toxins involved in multiorgan dysfunction secondary to liver failure. (Liver Transpl 2000;6: 603-613.)
Recently, significant improvement of renal function and prolongation of survival were reported in hepatorenal syndrome (HRS) patients treated with the Molecular Adsorbent Recirculating System (MARS). As no impact on extrarenal organ function was documented, this trial looked into multiple organ function changes during MARS in HRS patients. Eight HRS patients (4 male, mean age 42. 1 years, range 30–58, all United Network for Organ Sharing [UNOS] status 2A) were treated intermittendly 4–14 times (total 47, mean 5.9 ± 3.4) between 4 and 8 h/single treatment. The following changes were observed pre‐ and posttreatment: bilirubin 466 ± 146 to 284 ± 134 γmol/L, creatinine 380 ± 182 to 163 ± 119 μmol/L, urea 26.4 ± 10.3 to 12.9 ± 4.9 mmol/L, plasma sodium 127.5 ± 7.7 to 137.5 ± 4.8 mmol/L (all p < 0.01). Mean arterial pressure (MAP) increased from 71.9 ± 12.8 to 95.6 ± 7.8 Torr (p < 0.001). Oliguria or anuria, present in all patients, was successfully reverted. Ascites, present in all patients, was not detectable after the treatment period. The hepatic encephalopathy grade decreased from 2.8 ± 0.8 to 0.8 ± 0.7 (p < 0.0001). Child‐Index decreased from 13.25 ± 1.3 to 9.4 ± 1.8 (p < 0.001). The hospital survival rate was 62%. One man underwent successful liver transplantation 18 months after the treatment. We conclude that MARS can improve multiple organ functions in patients with HRS.
The pharmacokinetics of piperacillin-tazobactam were investigated in eight anuric intensive care patients treated by continuous venovenous hemodialysis (CVVHD). The elimination half-life of piperacillin was 4.3 ؎ 1.2 h, and that of tazobactam was 5.6 ؎ 1.3 h. The contribution of CVVHD to the overall elimination was relevant (>25%) for both drugs.Piperacillin-tazobactam is a -lactam--lactamase inhibitor combination with a broad spectrum of antibacterial activity against gram-positive as well as gram-negative pathogens. It is frequently used for the empirical treatment of infection in intensive care patients (2, 15). The aim of this investigation was to determine the pharmacokinetics of piperacillin-tazobactam in critically ill patients with acute anuric renal failure treated by continuous venovenous hemodialysis (CVVHD).Eight critically ill patients were included in the investigation (Table 1). Inclusion criteria were an age of Ͼ18 years, acute renal failure treated by CVVHD, anuria (Ͻ100 ml of urine/day), and treatment with piperacillin-tazobactam. Patients with severe liver failure or cholestasis were excluded. The protocol of the study was approved by the local ethical committee, and informed consent was obtained from a first-degree relative. CVVHD was performed with an AN69 hollow-fiber dialyzer (Multiflow 60; Hospal, Nuremberg, Germany) under the following conditions: a blood flow rate of 150 ml/min, a dialysate flow rate of 1.5 liters/h, and an ultrafiltrate flow rate of 80 to 200 ml/h. Doses of piperacillin-tazobactam (4.5 g of Tazobac; Wyeth-Lederle) and dosing schedules were chosen empirically by the attending physicians (Table 2). Piperacillin-tazobactam was administered intravenously over 15 min. Corresponding predialyzer blood samples and dialyzer-outlet dialysate samples were taken before drug administration, at 10 and 30 min after infusion, and at 1, 2, 4,6,8,12,20, 22, and 24 h after infusion. Sampling was performed in the first dosage interval after the dialyzer membrane was changed. Blood samples were centrifuged immediately after they were taken, and plasma and dialysate samples were frozen at Ϫ80°C until analysis. The concentrations of piperacillin and tazobactam were determined by reversed-phase high-performance liquid chromatography with UV detection, with modification of the methods reported previously (13, 16). Plasma specimens were deproteinated, and dialysate was used without pretreatment. The presence of piperacillin was determined from the water layer extracted with dichloromethane; tazobactam samples were derivatized with 1,2,3-triazole and injected without extraction. The chromatographic conditions for piperacillin were as follows: a guarded Nucleosil C 18 100-5/250 ϫ 4 column, an eluent of methanol-KH 2 PO 4 (1:1, vol/vol; 67 mM; pH 3), ambient temperature, a flow rate of 0.5 ml/min, a of 214 nm, and a retention time of ϳ20 min. The chromatographic conditions for tazobactam were as follows: a Superspher C 18 100-5/250 ϫ 4 column; an eluent of acetonitrile-Na 2 HPO 4 (1:3, vol/vol; ...
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